SummaryThe Forbes Regional Campus of Western Pennsylvania Hospital developed a number of strategies to reduce delays in patient admission and discharge, thereby facilitating patient flow through the emergency department. The goal was to avoid periods in which the hospital is on diversion (or "condition red") status, meaning that ambulances cannot come to the hospital. The program eliminated "condition red" hours at the hospital, significantly reduced waiting times for patients requiring an inpatient admission, and increased patient satisfaction.Moderate: The evidence consists of before-and-after comparisons of key outcomes measures, including number of condition red hours, percentage of patients being admitted within 3 hours of hospital arrival, and patient satisfaction.
Developing OrganizationsWestern Pennsylvania Hospital, Forbes Regional Campus
Date First Implemented2005
Problem AddressedHospitals that do not have available inpatient beds for emergency department (ED) patients often have to divert ambulances to another hospital (a situation commonly called "condition red" status). Aside from the negative implications for patient safety, condition red status also results in foregone revenues from patients who are turned away. Hospitals that have poor patient flow due to delays in admissions and discharges or other inefficient processes are more likely to require ambulance diversion.
- A common problem: The Emergency Medical Services Committee of the American College of Emergency Physicians Guidelines for Ambulance Diversion state that ambulance diversion should occur only after the hospital has exhausted all internal mechanisms to avert a diversion.1 Nevertheless, ambulance diversion remains routine in many hospitals due to inefficient patient flow processes.2
- Negative financial implications: Condition red status can result in a considerable loss of revenue. A study of one urban hospital's ED found that each hour spent on diversion resulted in $1,086 in forgone revenues.2 A financial analysis conducted by the Forbes Regional Campus of the Western Pennsylvania Hospital found that the hospital was losing approximately $3.1 million per year in revenues as a result of being on condition red status.3
- Negative impact on patient safety as well: Condition red status creates a threat to patient safety because of the potential to delay treatment.4
Description of the Innovative ActivityThe Forbes Regional Campus of Western Pennsylvania Hospital developed a number of strategies to improve patient flow and thus reduce delays in patient admissions and discharges, with the goal of avoiding "condition red" status. Key strategies include the following:
- Formalized bed meetings: Previously, a patient flow coordinator rounded on different units searching for information about bed availability and planned discharges. Now, the hospital holds twice-daily, 15-minute bed meetings at a set time and location. Meeting participants (approximately 10 to 12 people) include the patient flow coordinator and a representative from the ED and each unit (typically the clinical coordinator who supports the nurse manager). Participants discuss current bed availability and planned discharges so that the patient flow coordinator is aware of open beds and can direct patients accordingly.
- ED-based admissions nurses: Previously, admitting a new patient required unit nurses to complete roughly 45 minutes of administrative work, making them reluctant to accept new patients during busy times. To address this problem, the hospital assigned two nurses to serve as admissions nurses; these nurses, based in the ED, complete all data entry and other administrative work, thus minimizing the work required by unit nurses.
- Mini-evaluation by ED physician: Previously, ED patients with nonurgent needs waited to see an ED physician and then waited again for at least 1 hour while laboratory work was processed. Now, the ED physician conducts a "mini-evaluation" of patients before they are placed in an ED bed to determine the need for laboratory tests. The physician orders any needed tests and sends the patient back to the ED waiting room. By the time an ED bed becomes available, the patient's test results are typically back, thus ensuring a shorter wait time for the patient and more effective use of ED beds.
- Unit charge nurse who tracks patient flow: Previously, no unit staff member tracked patient flow. Now, the unit charge nurse takes responsibility for tracking daily bed availability and planned discharges. Anyone who needs to request a bed placement can quickly contact the nurse via a pager. (If the nurse is off the floor, he/she must designate a substitute to keep the pager and respond to requests for bed placement.) Rather than waiting for a call to request a bed, the unit charge nurse is encouraged to call the patient flow coordinator to proactively report when a bed becomes available.
- Direct request for intensive care unit (ICU) and telemetry beds: Rather than going through the patient flow coordinator, the ED charge nurse can call ICU and telemetry charge nurses directly to request a bed. This step eliminates potential delays, because the ED nurse typically has to convey critical clinical information to the receiving unit nurse before patient transfer.
- As-available discharge unit: Often patients are officially discharged from the hospital but cannot leave their room until they have a ride home. To more quickly reassign these beds, the hospital designated a medical short-stay unit that is typically underutilized in the afternoon to serve as a place for discharged patients to wait for a ride and, if needed, receive nurse-led education and medication review. (Use of this space as a discharge unit varies depending on its availability throughout the day.)
- Morning discharges to nursing homes: Previously, even though discharges generally occurred in the morning, patients being sent to nursing homes typically did not leave until the afternoon due to paperwork requirements and the need to arrange transportation. Now, unit nurses coordinate paperwork and transportation arrangements before the day of discharge for those being transferred to a nursing home, thus enabling those patients to leave in the morning.
- Prioritization of room cleanings: When multiple discharges occur simultaneously, the patient flow coordinator pages the environmental supervisor to prioritize room cleanings based on the anticipated timing of admissions.
- Dedicated ED-based transport staff: A portion of the transport staff is dedicated to the ED to facilitate timely patient transport to units. Due to resource constraints, this team also serves the radiology department.
- Expansion to a hospital-wide focus: Information provided in September 2010 indicates that the hospital is expanding its activities to ensure management of overcapacity on inpatient units, in addition to the ED. This change was based on the recognition that inpatient units can also reach a maximum capacity situation because of a surge of admissions, staffing situations, or other emergencies but did not have a system in place to call for help. To address this need, the hospital developed a four-stage classification for all units; unit staff defined and refined the criteria for all four stages and provide ongoing feedback. The four stages are:
- Green: All is "normal," and the unit can accept additional patients and help other units.
- Yellow: The unit is under moderate stress but should be able to self-correct without assistance.
- Orange: The unit needs assistance from other units and middle managers. Condition orange is a hospital-wide "one team" concept that prompts all units to respond quickly. Issues are promptly resolved via triage, and typically an orange alert is canceled within 45 to 60 minutes. Administrators send thank you notes to those who respond and review each condition orange status for future preventive actions.
- Red: The unit is in crisis; all available leaders should respond and take action to return the unit to at least a yellow status as soon possible.
References/Related ArticlesInstitute for Healthcare Improvement. Improvement Report: Doing an Extreme Makeover of Patient Flow: Going from Condition Red to Green in One Week (or Less). December 2005. Available at: http://www.ihi.org/knowledge/Pages/ImprovementStories/DoinganExtremeMakeoverofPatientFlowGoingfromConditionRedtoGreeninOneWeekorLess.aspx
Contact the InnovatorDiane Frndak, PhD, MBA, PA-C
Vice President of Organizational Excellence
West Pennsylvania Allegheny Health System
30 Isabella Street
Pittsburgh, PA 15212
Phone: (412) 330-2425
Cell: (412) 862-8850
Fax: (412) 330-2444
Innovator DisclosuresDr. Frndak has not indicated whether she has financial interests or business/professional affiliations relevant to the work described in this profile; however, information on funders is available in the Funding Sources section.
ResultsThis multipronged strategy eliminated condition red hours, reduced waiting times for patients requiring hospital admission, and increased patient and emergency medical services (EMS) staff satisfaction.
Moderate: The evidence consists of before-and-after comparisons of key outcomes measures, including number of condition red hours, percentage of patients being admitted within 3 hours of hospital arrival, and patient satisfaction.
- Elimination of condition red hours: Before the intervention, the number of condition red hours fluctuated, reaching as high as 183 hours a month. After implementing the program, the number of condition red hours decreased to 0.
- Shorter waits for an inpatient bed: The percentage of ED patients admitted within 3 hours of hospital arrival increased from 15 percent in July 2004 to 79 percent in July 2005.
- Higher patient satisfaction: The percentage of patients who were "satisfied" or "very satisfied" with inpatient care on the Press Ganey survey increased from 79.5 percent in March 2005 to 83.5 percent in August 2005, with a further increase to 86 percent as of December 2008. The number of complaints to the patient services representative decreased during this time.
- Higher EMS satisfaction: EMS staff reported being pleased with the changes, as they resulted in a faster intake process, thus allowing them to serve more patients.
Context of the InnovationThe Forbes Regional Campus of the Western Pennsylvania Hospital is a community hospital with 340 beds located in a suburb of Pittsburgh. The campus, which has three medical–surgical units, treats approximately 16,000 inpatients per year. In 2005, a financial analysis revealed that the hospital was losing approximately $3.1 million per year in revenues due to being on condition red status. This long-term problem had not been addressed adequately through previous strategies, so the hospital decided to try a new approach—a "Kaizen blitz" strategy. Embraced by the Toyota Production System as a performance improvement methodology, a Kaizen (Japanese for continuous improvement) blitz is a focused, short-term project to improve a process. The vice president of organizational excellence knew about the concept based on her previous work with Toyota Production System concepts.
Planning and Development ProcessKey elements of the planning and development process included the following:
- Planning the Kaizen blitz: A team, including the chief executive officer, chief nursing officer, patient flow coordinator, emergency medical director, director of ED services, all unit managers, manager of case management, patient service representative, and other leadership, along with the vice president of organizational excellence, created a plan to execute the Kaizen blitz over a 1-week period. Subteams addressed various issues, including collection of baseline data about patient flow, staff communication, and logistical aspects of planning the Kaizen blitz week.
- Staff communication: Nurse managers informed staff members about the Kaizen blitz, explaining the concept and inviting them to participate. Hospital staff also received e-mail reminders about the upcoming Kaizen blitz.
- Kaizen blitz week: The Kaizen blitz was held over the course of 1 week (7 a.m. to 5 p.m. daily) in a very large conference room.
- Blitz leaders: The vice president of organizational excellence, the chief nursing officer, all unit managers, and the patient flow coordinator served as program leaders, attending the vast majority of each day's discussions (although they floated in and out as necessary).
- Staff participants: Staff members (e.g., nurses, technicians, case mangers, unit managers/directors) came in at their convenience to share ideas for improving patient flow and/or to present a real-time problem. An estimated 200 different staff members participated in some capacity throughout the week.
- Solving real-time problems: When necessary, additional staff members came to the conference room to help solve real-time patient situations; sometimes, program leaders dispatched a "swat" team to look into the issue and return with information about the source of delays. Staff members could propose a solution and then try it on a limited basis (e.g., for the next five patients or for the afternoon).
- Increased staffing: The hospital increased staffing during this week to allow staff to participate and promote the ability to experiment with solutions; for example, after someone proposed the concept of placing an admissions nurse in the ED, the team allocated a nurse to serve in this role the following day.
- Tracking ideas: Discussion leaders wrote proposed solutions and other ideas on flip-chart paper hung around the room. This process helped in tracking ideas and implementing process improvements.
- Debriefs: The team held debriefs twice daily (at 10 a.m. and 4 p.m.) to review progress on the experiments, obtain feedback, and make adjustments if necessary.
- Adoption of new ideas: Participants came up with more than 100 ideas during the week, many of which were tested on a limited-time basis. Those deemed successful were instituted permanently.
Resources Used and Skills Needed
- Staffing: Development and implementation of the program required no new staff.
- Costs: Approximately $1,100 was spent on food, T-shirts, balloons, and other items distributed during the Kaizen blitz week.
Funding SourcesWestern Pennsylvania Hospital, Forbes Regional Campus
Tools and Other ResourcesMany books exist on the Toyota Lean Production System and the Kaizen blitz strategy. Examples include:
- Laraia AC, Moody PE, Hall RW. The Kaizen blitz: accelerating breakthroughs in productivity and performance. Washington, DC: National Association of Manufacturers; 1999.
- Dailey KW. The Kaizen pocket handbook. Grand Blanc, MI: DW Publishing Company; 2005.
- Alukal G, Manos A. Lean Kaizen: a simplified approach to process improvements. Milwaukee, WI: ASQ Quality Press; 2006.
Getting Started with This Innovation
- Pursue real-time problem-solving: Asking staff members to solve problems as they experience them is often more efficient, compelling, and successful than designing strategies after an analysis of retrospective data.
- Run a Kaizen blitz round-the-clock: Ideally, the Kaizen blitz should be run around the clock and on weekends to address problems that arise on night and weekend shifts.
- Generate ideas internally: Best practices can be informative but not necessarily applicable to a particular institutional environment. In addition, generating ideas internally helps facilitate staff buy-in to the proposed process change(s).
Sustaining This Innovation
- Monitor processes to ensure gains are sustained: Ongoing monitoring and support helps ensure that staff do not regress to old strategies or accept process inefficiencies as "business as usual."
Additional Considerations and Lessons
- Avoid using condition red as a "crutch": Going on condition red may be necessary at times to ensure that patients receive the safest, most timely care. However, institutions should not use condition red as an excuse to avoid solving systemic inefficiencies.
McConnell K, Richards CF, Daya M, et al. Ambulance diversion and lost hospital revenues. Ann Emerg Med. 2006;48(6):702-10. [PubMed]
3 Interview with Diane Frndak, January 15, 2009.
Trzeciak S, Rivers EP. Emergency department overcrowding in the United States: an emerging threat to patient safety and public health. Emerg Med J. 2003;20:402-5. [PubMed]
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Service Delivery Innovation Profile
Original publication: September 30, 2009.
Original publication indicates the date the profile was first posted to the Innovations Exchange.
Last updated: November 07, 2012.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.
Date verified by innovator: October 04, 2010.
Date verified by innovator indicates the most recent date the innovator provided feedback during the annual review process. The innovator is invited to review, update, and verify the profile annually.